What is a medication prior authorization?

Imagine this scenario…ValuMedPharmacyPriorAuthorization
You’ve just walked out of your physician’s office with a prescription following a routine visit. You take the prescription to your favorite local pharmacy, only to find out that your insurance company is denying the claim and requiring something called a Prior Authorization. The pharmacist informs you it may take some time, and extra paperwork for your physician to get the prescription approved, but you still leave the store frustrated and somewhat confused by the process. What now???
We understand how much of an inconvenience these prior authorizations can be and would like to take a few moments to better explain what they are, the process involved to get them approved, and what you can do to help. Here’s a few answers to some commonly asked questions regarding Prior Authorizations

What is a Prior Authorization?
-A Prior Authorization, or PA, is an additional step, or series of steps that some insurance companies may require before they determine if they will cover a medication. Typically, a prescriber will need to contact your insurance company and provide more information as to why the specific medication is medically necessary for you.

What types of medications require a PA?
-There are several reasons why insurance companies may require a PA, but they mostly revolve around cost of the medication and whether or not the medication is medically necessary. Here’s a few common reasons for PAs:
a. A patient or physician is requesting a Brand name drug although there is a generic equivalent available.
b. The medication is very expensive
c. The medication may have an age range or limit that it is typically used for.
d. The medication is not on the formulary and there are other similar medications that the insurance company prefers
e. Medications used for cosmetic purposes or for non-life-threatening conditions

How long does a prior authorization take to complete?
– This depends on several factors including which insurance company you have and how quickly your physician can get the necessary paperwork to your insurance. Typically, we ask patients to expect 48-72 hours before approval (or denial) is determined by your insurance company.

What can I do to help with the process?
-Contact you prescriber’s office to let them know the medication requires prior authorization.
– Ask your prescriber how long it typically takes for them to complete the necessary PA paperwork.
-Contact your insurance company to make sure there are not any additional steps that you need to take to complete the process.
-Allow your prescriber and insurance company enough time to complete their end of the process
-Check back with the pharmacy to see if the PA was approved.
-If your medication was not approved, call your insurance to find out why.

Unfortunately, prior authorizations are becoming a very common part of the medication filling process. We at Valu-Med Pharmacy understand how frustrating this can be at times, but we are here for you with any questions you may have. We hope to continue to make the process as smooth as possible and never hesitate to call us for information.

Contact Number        (405) 741-1200